Child Protective Services Intake Form
Reporter Information
Full Name
Relationship to Child
Phone Number
Email
Child Information
Full Name
Date of Birth
Gender
Male
Female
Other
Age
Address
Parent/Guardian Information
Full Name(s)
Relationship to Child
Phone Number
Allegation Details
Type of Allegation
Neglect
Physical Abuse
Sexual Abuse
Emotional Abuse
Other
Description of Concern
Date and Time of Incident
Location of Incident
Other Individuals Involved
Names and Relationships
Additional Information
Other Relevant Details